In a previous e-weekly, we discussed assessment and treatment of obsessive-compulsive disorder (OCD). It is well known that OCD is a chronic waxing and waning disorder. The hidden nature of symptoms and the reinforcement provided by the reduction in anxiety after performing a compulsion contribute to sustained illness. Once the diagnosis of OCD is made, first line treatment includes the SSRIs and/or CBT (exposure response prevention –ERP – is the specific form of CBT used for OCD). Once two adequate trials of SSRIs have been made, the next step is a trial of clomipramine and/or using augmentation strategies like the atypical antipsychotic medications. This initial treatment course has been shown to be effective for 50-60% of patients. The goal of treatment is to decrease distress, interference, and the frequency of symptoms to a minimal level.
If there is concern about inadequate response to treatment, the first course of action is to add ERP if the patient is not already engaged in therapy. Other forms of therapy, including general CBT for anxiety are not as helpful specifically for OCD symptoms. It is also important to re-evaluate the diagnosis, to make sure there are not untreated co-morbid conditions that are making it challenging to treat the primary OCD disorder. If there is untreated co-morbid Major Depression or ADHD or Bipolar Disorder, that could impact the treatment response for the OCD.
If a patient is showing a partial response to a moderate dose of an SSRI, for example Prozac 40mg per day, one could consider increasing the dose to higher than usually used to treat depression and anxiety, for example Prozac 60-80mg per day. This is not a useful intervention if there is no response to the lower dose of the medication. If the medication is increased, it is important to monitor for adverse effects, which are more likely to occur at higher doses. One would have to be cautious if considering using an SSRI and clomipramine together, because of the increased risk for serotonin syndrome.
Other augmentation strategies have been studied to a certain extent. Many of these are glutamate modulating agents. N-acetylcysteine (NAC) has been studied in both adults and children, with mixed results. It is often tried as an augmentation strategy because it has a benign side effect profile. It would be dosed up to 3g/day in divided doses. Memantine, which is commonly used in Alzheimer’s disease, has shown promising results for treatment refractory OCD at doses of 20mg per day. Case studies for the mood stabilizer lamotrigine, have shown it to be somewhat helpful as augmentation with SSRIs with significant decrease in YBOCs scores (The YBOC is the Yale-Brown Obsessive Compulsive Scale and is used to measure the severity of OCD symptoms). Doses are between 100-200mg per day. The benzodiazepines are helpful for other anxiety disorders but have not been found to be helpful for OCD symptoms.
Given that OCD is more prevalent than previously thought and can be challenging to detect for various reasons, it is important that primary care providers are comfortable with screening for OCD in patients presenting with mental health concerns, as well as being familiar with appropriate treatment referrals. SmartCare Patient and Parent Line can be a useful resource for families to find specific referrals for treating OCD, including treatment-resistant OCD.